Equitable and sustainable funding for community-based organisations in global mental health
Authors: June Larrieta, Milena Wuerth, May Aoun, Dörte Bemme, Nicole D'souza, Nyaradzayi Gumbonzvanda, Georgina Miguel Esponda, Tessa Roberts, Angi Yoder-Maina, Emilia Zamora, Onaiza Qureshi, Rita Giacaman
Journal: The Lancet Global Health (2023)

Community-based organisations working in mental health are essential for supporting wellbeing globally, particularly in areas where other services are scarce. Such organisations are uniquely attuned to local needs, challenges, and priorities, often established and led by members of a particular community themselves. Thus, community-based organisations provide culturally relevant services and programmes within familiar environments by trusted providers, whereby community participation is central to their implementation.1Campbell C Burgess R The role of communities in advancing the goals of the Movement for Global Mental Health.Transcult Psychiatry. 2012; 49: 379-395Crossref PubMed Scopus (100) Google Scholar, 2Kohrt B Asher L Bhardwaj A et al.The role of communities in mental health care in low- and middle-income countries: a meta-review of components and competencies.Int J Environ Res Public Health. 2018; 151279Crossref PubMed Scopus (140) Google Scholar However, existing global health funding mechanisms hinder community-based organisations from accessing resources to sustain their work, instead favouring large, professional organisations, often partnered with academic institutions in high-income countries. At present, the global health funding landscape is built on priorities, processes, and definitions of funders in the Global North, leading to the disproportionate scrutinisation of community-based organisations in the Global South (we use the terms Global South and Global North while recognising their geographical inaccuracies and that these divisions indicate the geospatial distribution of power and resources, both historically and at present, and colonial histories).3Khan T Abimbola S Kyobutungi C Pai M How we classify countries and people—and why it matters.BMJ Glob Health. 2022; 7e009704Crossref Scopus (32) Google Scholar To facilitate change, important questions should be raised about whose priorities and knowledge matter, to which we bring our collective expertise as global health researchers, practitioners, and implementers.4Büyüm AM Kenney C Koris A Mkumba L Raveendran Y Decolonising global health: if not now, when?.BMJ Glob Health. 2020; 5e003394Crossref PubMed Scopus (148) Google Scholar As we reflect on these problems and provide recommendations for funders, we call for a radical shift towards funding mechanisms that recognise communities and community-based organisations as active agents of change, and that complement their local experience and knowledge. In this Comment, we focus on mental health, but the key arguments apply more broadly. Financial resources for mental health are scarce and rarely allocated in alignment with the needs of community-based organisations.5Iemmi V Philanthropy for global mental health 2000–2015.Glob Ment Health. 2020; 7: e9Crossref Google Scholar, 6WHOWorld mental health report: transforming mental health for all.https://www.who.int/publications/i/item/9789240049338Date: 2022Date accessed: October 1, 2022Google Scholar Several factors disadvantage community-based organisations applying for grants,7Iemmi V Motivation and methods of external organisations investing in mental health in low-income and middle-income countries: a qualitative study.Lancet Psychiatry. 2021; 8: 630-638Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 8Larrieta J Miguel Esponda G Gandhi Y et al.Supporting community-based mental health initiatives: insights from a multi-country programme and recommendations for funders.BMJ Glob Health. 2022; 7e008906Crossref PubMed Google Scholar including: 1) digital engagement requirements, which are inaccessible for organisations with minimal digital infrastructure; 2) pre-requisites of having previously received funding, which excludes newer organisations; 3) English as the dominant language; 4) the use of technical jargon that alienates programme implementers and; 5) misalignment between the priorities of funders (eg, scaling up mental health programmes) and community needs (eg, sustainability of programmes to ensure long-term recovery of community members involved). Grants often exclude core operational costs, thwarting sustainable programming.8Larrieta J Miguel Esponda G Gandhi Y et al.Supporting community-based mental health initiatives: insights from a multi-country programme and recommendations for funders.BMJ Glob Health. 2022; 7e008906Crossref PubMed Google Scholar, 9Boyes-Watson T Bortcosh S Breaking the starvation cycle: how international funders can stop trapping their grantees in the starvation cycle and start building their resilience. Humentum, Oxford2022https://humentum.org/wp-content/uploads/2022/03/Humentum-ACR-Research-Report-FINAL.pdfDate accessed: September 27, 2022Google Scholar For example, restrictions placed on human resources can impede the payment of dignified salaries to experienced staff, leading to high turnover or reliance on unpaid workers. Furthermore, resources necessary to fulfil extensive reporting requirements are often unaccounted for and their relevance to community-based organisations are overlooked; frequently requested quantitative impact metrics (eg, use of a Patient Health Questionnaire), for example, might not be feasible or pertinent to community-based organisations and might not capture contextual factors that influence outcomes (eg, poor engagement in phone-based interventions among women with depression due to low connectivity or requiring permission from male partners to use the technology). Community-based organisations might seek academic collaborations to fulfil the requirements of funders only to have much of this budget allocated towards the indirect costs associated with academic institutions.10Stoecker R Challenging institutional barriers to community-based research.Action Res. 2008; 6: 49-67Crossref Scopus (47) Google Scholar Funding applications must be simplified, particularly in the early stages to avoid depleting organisations' resources (eg, shorter forms, clear instructions, templates), and diversified, to minimise language-associated barriers (eg, allowing multilingual submissions via email, Zoom, paper applications, or in-person meetings for individuals without stable internet connections). Once partnerships are established, funders should actively support the financial independence of community-based organisations, engaging in active communication with grantees to understand needs and counteract top-down funding models.8Larrieta J Miguel Esponda G Gandhi Y et al.Supporting community-based mental health initiatives: insights from a multi-country programme and recommendations for funders.BMJ Glob Health. 2022; 7e008906Crossref PubMed Google Scholar, 9Boyes-Watson T Bortcosh S Breaking the starvation cycle: how international funders can stop trapping their grantees in the starvation cycle and start building their resilience. Humentum, Oxford2022https://humentum.org/wp-content/uploads/2022/03/Humentum-ACR-Research-Report-FINAL.pdfDate accessed: September 27, 2022Google Scholar Multi-year funding models would enable organisations to develop meaningful, long-term programmes; at present, the majority of grants are short-term, thus community-based organisations often have to start and stop programmes frequently or reshape services to fit available grants. Flexible core funding is crucial to cover the operational costs of community-based organisations and to provide agility in supporting programme objectives. Financial awards could be complemented by mentorship to develop fundraising skills or build alternative funding models (eg, social enterprises, membership systems, or crowdfunding campaigns).8Larrieta J Miguel Esponda G Gandhi Y et al.Supporting community-based mental health initiatives: insights from a multi-country programme and recommendations for funders.BMJ Glob Health. 2022; 7e008906Crossref PubMed Google Scholar Peer networking opportunities would also help organisations to develop partnerships. Funders must recognise that evidence-generating mechanisms are only viable when integrated with the day-to-day operations and aims of community-based organisations. This integration requires wider acceptance of outputs that are qualitative or based on non-biomedical understandings of mental health, and acknowledgement of resources needed to conduct impact assessments. Considering the little funding available for mental health programmes, achieving sustainable and equitable funding for community-based organisations would require reform of funding structures to shift power to local stakeholders and recognise community-based organisations as equal players in the improvement of community-level health outcomes. By implementing our propositions, funders can co-create mutualistic relationships shaped around the resources, knowledge, and agenda of community-based organisations. This reorientation is necessary for community-based organisations and those they support to thrive. JL is Research, Monitoring, and Evaluation co-lead for Ember Mental Health, a programme of the SHM Foundation. TR is funded by a British Academy Post-Doctoral Fellowship, and is a co-investigator on a programme entitled SCOPE from the Wellcome Trust. NG holds a role as a AU Goodwill Ambassador on Ending Child Marriage and as board chair for Action Aid. GME is an affiliate researcher at King's College London, Strategic Information and Impact Manager at Compañeros de Salud, and Research, Monitoring, and Evaluation co-lead for Ember Mental Health, a programme of the SHM Foundation. JL, DB, TR, and MW received financial support from King's College London or King's Together Fund to support this work. All other authors declare no competing interests. The views expressed are the authors' own and do not necessarily represent the views, decisions, or policies of their respective institutions. This work was supported by the Economic and Social Research Council, Centre for Society and Mental Health at King's College London (ES/S012567/1); the King's Together Fund at King's College London; and the Impact Fund of the Department for Global Health and Social Medicine at King's College London.